Case Study: Right Temporal Lobe Epilepsy

Case Study:

Right temporal lobe epilepsy Group Members • Rudolf Cymorr Kirby P. Martinez • Yet dalen • Rachel Joy Alcalde • Siriwimon Luanglue • Mary Antonette Pineda • Khayay Hlaing • Luch Bunrattana • Keo Sereymonica • Sikanal Chum • Pyone Khant khant • Men Puthik • Chheun Chhorvy Advisers: Sudasawan Jiamsakul Janyarak Supat

2 Overview of Epilepsy

3 Overview of Epilepsy

4 Risk Factor of Epilepsy

5 Goal of Epilepsy Care

6 Case of Patient X Patient Information & Hx

• Sex: Female (single) • Age: 22 years old • Date of admission: 15 June 2017 • Chief Complaint: Jerking movement of all 4 limbs • Past Diagnosis: Temporal lobe epilepsy • No allergies, family history & Operation

Complete Vaccination. (+) Developmental Delay Now she can take care herself. Income: Helps in family store (can do basic calculation)

History Workup Admission Operation ICU Female Surgery D/C 7 • Sex: Female Case of Patient X • Age: 22 years old • CC: Jerking movement of all 4 limbs

History

Past Present

History Workup Admission Operation ICU Female Surgery D/C 8 • Sex: Female Case of Patient X • Age: 22 years old • CC: Jerking movement of all 4 limbs Past Present

(11 mos) (+) high fever. Prescribed AED for 2-3 Treatment at Songkranakarin Hosp. mos. After AED stops, no further episode Prescribe AED but still with 4-5 ep/mos

21 yrs 6 yrs Present PTA PTA

(15 y/o) (+) jerking movement (15 y/o) (+) aura as jerking Now 2-3 ep/ mos both arms and legs with LOC movement at chin & headache Last attack 2 mos for 5 mins. Drowsy after attack ago thus consult with no memory of attack 15-17 episode/ mos

History Workup Admission Operation ICU Female Surgery D/C 9 • Sex: Female Case of Patient X • Age: 22 years old • CC: Jerking movement of all 4 limbs Past Present

2 months prior to admission, she had jerking movement both arms and legs, blinking both eyes, corner of the mouth twitch, and drool. She had seizure about 1 minutes. After that she still drowsiness, she can’t answer the question. 3 minutes after, she can answer questions appropriately

History Workup Admission Operation ICU Female Surgery D/C 10 Case of Patient X Imaging & Laboratories 11

MRI: (03 April 2016) HLA-B*1502: negative relatively small right hemisphere with encephalomalacic change on right temporal lobe Psychological Test: WAIS-IV and WMS-III VDO EEG: (27 Feb - 3rd Mar 2017) generalized epilepsy and focal epilepsy arising Chest X-ray: Normal from the bilateral fronto- temporal regions. Two clinical seizures, consisting right eyes head versive Urinalysis: Normal then axial tonic seizures then generalized tonic seizure association with left fronto-temporal EEG Principle Diagnosis: seizure patterns were recorded. There is also Right temporal lobe evidence of structural abnormality in the setting of epilepsy/Intractable mild severe diffuse encephalopathy. epilepsy/Mental retardation

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 12

15 June, 2017

Vital Sign Maintenance T= 37 C; P=98/min; Pb (60mg) RR=20/min; 1.5 tab HS BP=114/60 mmHg Levi (500mg) 2 Pre-op Meds tab BID PC

Cefazolin 2g LTG(100mg) Single dose 1.5 tab BID PC

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 13

15 June, 2017 16 June, 2017

Vital Sign Maintenance R Temporal T= 37 C; Lobectomy P=98/min; Pb (60mg) RR=20/min; 1.5 tab HS BP=114/60 No complications mmHg Levi intraop (500mg) 2 Pre-op Meds tab BID PC Trans-out the next day Cefazolin 2g LTG(100mg) Cefazolin 1g q Single dose 1.5 tab BID PC 6hr for 4 doses

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 14

15 June, 2017 16 June, 2017 17 June, 2017

Fentanyl 50 mcg/ Vital Sign Maintenance R Temporal IV q 4hr PRN T= 37 C; Lobectomy P=98/min; Pb (60mg) 1 epilepsy ep RR=20/min; 1.5 tab HS (6am) BP=114/60 No complications intraop mmHg Levi Loss cons;, move (500mg) 2 her arms and legs Pre-op Meds tab BID PC Trans-out the next day without direction Cefazolin 2g LTG(100mg) then corner of the Cefazolin 1g q Single dose 1.5 tab BID mouth twitch for PC 6hr for 4 doses 20 minutes

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 15

Post op seizure attack 17 June, 2017 1 epilepsy ep Ictal Post ictal 30 (6am) mins. GCS E 2-3, M5, V2 E 3, M6, V5 Loss cons;, move her arms and legs without direction Pupillary reflex 3 mm RTL BE 3 mm RTL BE then corner of the mouth twitch for 20 minutes Muscle strength 4 on all 4 on all extremities extremities Valium 10mg/IV

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 16

15 June, 2017 16 June, 2017 17 June, 2017 18 June, 2017

Fentanyl 50 mcg/IV No complications Vital Sign Maintenance R Temporal D/C: June 20 T= 37 C; Lobectomy 1 epilepsy ep P=98/min; Pb (60mg) (6am) RR=20/min; Maintenance 1.5 tab HS No complications BP=114/60 Loss cons;, move intraop mmHg Levi her arms and legs Ibuprofen (500mg) 2 without direction (400mg) BID Pre-op Meds tab BID PC Trans-out the for 10 doses next day then corner of the mouth twitch for Cefazolin 2g LTG(100mg) Para (500) Cefazolin 1g q 20 minutes Single dose 1.5 tab BID PRN every 6 PC 6hr for 4 doses Valium 10mg/IV hours History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 17

Post op seizure attack Before discharge 18 June, 2017

– June 17 (ICU) (June 18) No complications

Ictal Post ictal D/C: June 20 30 mins. Maintenance GCS E 2-3, E 3, M6, V5 E 4, M5, V6 M5, V2 Ibuprofen Pupillary 3 mm 3 mm RTL 3 mm RTL BE (400mg) BID reflex RTL BE BE for 10 doses Muscle 4 on all 4 on all 5 on all extremities Para (500) strength extremiti extremities PRN every 6 es hours

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 18

15 June, 2017 16 June, 2017 17 June, 2017 18 June, 2017

Fentanyl 50 mcg/ IV q Mech of action 4hr PRN Diazepam 10mg/IV Common Side Effects Pb (60mg) 1.5 tab HS

Levi (500mg) 2 tab BID PC Adverse Reaction LTG(100mg) 1.5 tab BID PC

Ibuprofen (400mg) BID for 10 doses

Para (500) PRN every 6 hr

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 20 Cefazolin 2g SD then 1g q 6h for 4 doses Cephalosporin – binds to 1 or more Fentanyl 50 mcg/ IV q of the penicillin-binding proteins 4hr PRN Diazepam 10mg/IV Diarrhea, stomach cramps, oral candidiasis, vomiting, nausea, skin rash, phlebitis Pb (60mg) 1.5 tab HS

Levi (500mg) 2 tab BID PC Pseudomembranous colitis, anorexia, eospinophilia, Steven Johnson’s syndrome, LTG(100mg) 1.5 tab BID PC increased BUN and creatinine, renal failure, genital and anal pruritus, Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 21 Cefazolin 2g SD then 1g q 6h for 4 doses Potent opioid analgesic that increases pain threshold, alters pain reception and inhibits ascending pain Fentanyl 50 mcg/ IV q pathways by binding to stereospecific receptors w/in 4hr PRN the CNS. Diazepam 10mg/IV

Pb (60mg) 1.5 tab HS Bronchoconstriction, laryngospasm, nausea, vomiting, bradycardia, edema, dizziness, drowsiness, Levi (500mg) 2 tab BID PC hypotension, increased ICP, itching, rash LTG(100mg) 1.5 tab BID Potentially fatal respiratory depression, epistaxis, PC dental carries, gum line erosion, taste perversion Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 22 Cefazolin 2g SD then 1g q 6h for 4 doses Long-acting benzodiazepine with anticonvulsant, Fentanyl 50 mcg/ IV q anxiolytic, sedative – increases neuronal membrane 4hr PRN Diazepam 10mg/IV Shakiness and unsteady walk, trembling, or other problems with muscle control or coordination Pb (60mg) 1.5 tab HS

Levi (500mg) 2 tab BID PC Abdominal or stomach pain, black tarry stools, blurred vision, dark urine, decrease urine output, tachycardia, LTG(100mg) 1.5 tab BID PC increased muscle spasms, slurred speech, trouble concentrating, vomiting of blood Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 23 Cefazolin 2g SD then 1g q 6h for 4 doses Long-acting barbiturate- depresses the sensory Fentanyl 50 mcg/ IV q cortex, reduces motor activity, changes cerebellar 4hr PRN function and produces sedation Diazepam 10mg/IV

Pb (60mg) 1.5 tab HS Residual sedation, drowsiness, lethargy, vertigo, nausea, vomiting,headache Levi (500mg) 2 tab BID PC

LTG(100mg) 1.5 tab BID Bradyardia, hypotension; anxiety, CNS excitation or PC depression, hyperkinesias, constipation, Ibuprofen (400mg) BID hypoventilation, respiratory depression for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 24 Cefazolin 2g SD then 1g q 6h for 4 doses Anticonvulsant - partially reverses the reductions in GABA- Fentanyl 50 mcg/ IV q and glcine-gated curents induced by zinc and B-carbolines 4hr PRN Diazepam 10mg/IV

Pb (60mg) 1.5 tab HS Drowsiness, psychoneurosis, headache, nasopharyngitis, agitation, anxiety, Levi (500mg) 2 tab BID PC

LTG(100mg) 1.5 tab BID PC Depression, insomnia, irritability, rash, hostility, aggression Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 25 Cefazolin 2g SD then 1g q 6h for 4 doses Anticonvulsant - partially reverses the reductions in GABA- Fentanyl 50 mcg/ IV q and glcine-gated curents induced by zinc and B-carbolines 4hr PRN Diazepam 10mg/IV Drowsiness, psychoneurosis, headache, nasopharyngitis, Pb (60mg) 1.5 tab HS agitation, anxiety, Levi (500mg) 2 tab BID PC

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 26 Cefazolin 2g SD then 1g q 6h for 4 doses Analegesic, anti-inflammatory- inhibits synthesis of Fentanyl 50 mcg/ IV q prostaglandins in body tissues by inhibiting cyclooxygenase- 4hr PRN 1 and 2. Diazepam 10mg/IV

Pb (60mg) 1.5 tab HS Dizziness, headache, nervousness, epigastric pain, nausea, decreased appetite , constipation, vomiting, flatulence Levi (500mg) 2 tab BID PC LTG(100mg) 1.5 tab BID Hypoglycemia, GI disorder, apnea, respiratory infection, PC sepsis, fluid retention, hematuria necrotizing enterocolitis, Ibuprofen (400mg) BID andrenal insufficiency, increased BUN, UTI for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 27 Cefazolin 2g SD then 1g q 6h for 4 doses Analgesic, antipyretic- peripheral blockage of pain impulse Fentanyl 50 mcg/ IV q generation. 4hr PRN Diazepam 10mg/IV Thrombocytopenia leukopenia, pancytopenia, pain and Pb (60mg) 1.5 tab HS burning sensation at injection site, rarely hypotension and tachycardia Levi (500mg) 2 tab BID PC SJ syndrome, toxic epidermal necrolysis, acute generalized LTG(100mg) 1.5 tab BID PC exanthematous pustulosis, acute renal tubular necrosis, hepatotoxicity Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Nursing Care Plans 28

Sign and Symptoms

Nursing Diagnosis Nursing Interventions

Outcome (Planning)

Pre-operative Post-operative Admission ICU Female Surgery

Risk for Infection related to Risk for injury related to Pain related to operation impaired tissue sec to seizure activity operation Case of Patient X Nursing Care Plans S/Sx Plan 29 ND NI (+) History of seizure attack • Ensure safety and initiate seizure precautions for patients at-risk for seizures. This includes having suction set up and Risk for injury related to working, having an ambu-bag in the room, padding side rails, not restrain them or putting anything in their mouth if seizure activity a seizure occurs, having all side rails up, and so forth. • Maintain airway Stop any current seizure • Assess, monitor, and document seizure activity. activity as soon as possible, • Use and pad side rails with bed in lowest position, or place minimize damage, and bed up against wall and pad floor if rails not available or prevent it from occurring in appropriate. • Use and pad side rails with bed in lowest position, or place the future bed up against wall and pad floor if rails not available or appropriate.

Pre-operative Post-operative Admission ICU Female Surgery Case of Patient X Nursing Care Plans S/Sx Plan 30 ND NI (+) History of seizure attack • Avoid using thermometers that can cause breakage. Use tympanic thermometer when necessary to take Risk for injury related to temperature. • Administer antiepileptics (PRN and scheduled) medications seizure activity per orders • Reevaluate any medications that may lower the seizure Stop any current seizure threshold (some antibiotics, antidepressants, narcotics, and activity as soon as possible, many more may do this) minimize damage, and • Educate patient and family on hospital procedures, and prevent it from occurring in when to notify staff • Provide emotional support to patient and family the future

Pre-operative Post-operative Admission ICU Female Surgery Case of Patient X Nursing Care Plans 31

(+) History of seizure attack

Risk for injury related to seizure activity

Stop any current seizure activity as soon as possible, minimize damage, and prevent it from occurring in the future

Pre-operative Post-operative Admission ICU Female Surgery Case of Patient X Nursing Care Plans S/Sx Plan 32 ND NI (+) S/p Right Lobectomy • perform actions to reduce fear and anxiety about the pain experience (e.g. assure client that his/her need for pain Pain related to operation relief is understood, plan methods for achieving pain control with client) 1. verbalization of a • administer analgesics before activities and procedures that decrease in or absence of can cause pain and before pain becomes severe pain 2. relaxed facial expression • perform actions to promote rest (e.g. minimize and body positioning environmental activity and noise) in order to reduce fatigue and subsequently increase the client's threshold and 3. increased participation tolerance for pain in activities 4. stable vital signs Pre-operative Post-operative Admission ICU Female Surgery Case of Patient X Nursing Care Plans S/Sx Plan 33 ND NI (+) S/p Right Lobectomy • provide or assist with nonpharmacologic methods for pain Pain related to operation relief (e.g. massage; position change; progressive relaxation exercises; restful environment; diversional activities such as 1. verbalization of a watching television, reading, or conversing) decrease in or absence of • securely anchor drainage tubes to decrease tissue irritation pain resulting from movement of tubes 2. relaxed facial expression • administer the anti-pain meds as ordered and body positioning 3. increased participation in activities 4. stable vital signs Pre-operative Post-operative Admission ICU Female Surgery Case of Patient X Nursing Care Plans S/Sx Plan 34 ND NI (+) S/p Right Lobectomy • Use good handwashing technique and encourage client to do the same Risk for Infection related to • Instruct client to avoid touching incisions, dressings, drainage tubings, and open wounds impaired tissue sec to operation • Use sterile technique during all dressing changes & wound care • Replace equipment and solutions used for wound care The client will remain free according to hospital policy in order to reduce the risk of of wound infection colonization of microorganisms • Protect client from others with infections • Administer antimicrobials if ordered • Refer if with sign/ symptoms of infection Pre-operative Post-operative Admission ICU Female Surgery Case of Patient X Discharge Plans 35

D M E T H O D

Discharge planning process should be initiated as soon as possible after patient admission

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 36

D M E T H O D

Disease: Right Temporal Lobe Epilepsy s/p Right Lobectomy

Focus on maintaining QOL; Decrease number of seizure episode

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 37

D M E T H O D

Medication: Continuity

Emphasize proper taking of medication with 5 R’s. Emphasize that maintenance should NEVER be discontinued as well as it’s side effects and adverse reaction

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 38

D M E T H O D

Environment: Prevent Injury

Modify home to promote safety such as on-slipping floor; installation of side rails to normal bed and hand rails to toilet

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 39

D M E T H O D

Treatment: AED & Rehabilitation

Emphasize need for continued home exercise (ROM exercise) and follow up with physiotherapist. Encourage family to provide emotional support

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 40

D M E T H O D

Health Promotion: Prevention of Attack & Safety Issues

Focus on teaching family members basic first aid during attack; proper AED administration. Promote family involvement in patient care

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 41

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 42

D M E T H O D

Out Patient: July 17 @ Neurosurgery

Emphasize need for follow up as advised by physician and never to miss any appointment

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 43

D M E T H O D

Diet: High Fat, Low Carb, Adequate Protein

Encourage family members to prepare foods as mentioned if patient can tolerate

History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Discharge Plans 44

History Workup Admission Operation ICU Female Surgery D/C mrmiN+ slmt=

Thank You cảm ơn bạn Salamat PhD, MA, RN, CAA, LMT, CSTP, FRIN

ResearchGate: https://goo.gl/dNr2Zs